A: Before having anything to eat or drink in the mornings, the blood sugar numbers are generally recommended to be around 100. Before meal blood sugars would be about the same.

Blood sugar readings about two hours after the start of your meals may go up about 40 units above the before-meal readings. If your blood sugar was 100 immediately before you started your noon meal, then your blood sugars may go to 140. Your physician or diabetes educator may have a more specific blood sugar targets for you.

A: There are several factors that can cause high blood sugars in the mornings. Your body has stored sugar inside your liver during the day and sometimes releases this sugar into your bloodstream when you are not eating (such as during sleep). For people taking insulin, blood sugars may be high in the morning when they did not receive enough insulin at bedtime or the bedtime insulin may wear out by morning. Hormones that are released overnight some times work against the action of insulin. These events can cause your blood sugar levels to rise in the morning.

When you notice frequent and consistent high blood sugars in the morning, or any time, contact your doctor or diabetes educator. Bring your blood sugar log book to your appointment. This information will be very help for updating your diabetes care plan. - Liz Quintana, MS, RD, LD, CDE

The rise in blood sugar is common after highly vigorous exercise, particularly if blood glucose levels were already high before exercise. High intensity physical activity releases stress hormones, which can cause the liver to send sugar into the blood stream. The blood sugar typically drops slowly in the hours after exercise once the stress hormones are no longer in the blood. In comparison, moderate activity such as walking usually lowers blood sugar level.

Always check with your health care team before starting a new exercise program. They can tell you when it's safe for you to exercise, when and how often to check your blood sugar, and what to do should you experience symptoms of low blood sugar. Additional information is available from dLife:

A: If your blood sugars are consistently high, you may need to revise your diabetes care plan. As diabetes progresses, your body may not be responding the same way as it did during earlier times. Your treatment may need to be updated to meet current blood sugar levels.

A: Blood sugar that remains high for long periods of time can cause serious health problems if it's not treated. Hyperglycemia (high blood sugar) can cause damage to the vessels that supply blood to vital organs. This can increase the risk of heart disease and stroke, kidney disease, vision problems, and nerve problems in people with diabetes.

A single high blood sugar reading usually isn't cause for alarm - it happens to everyone with diabetes from time to time. However, if you're having high blood sugar levels a lot, let your diabetes health care team know. Your diabetes care plans may need adjusting. - Liz Quintana, MS, RD, LD, CDE

A: Low blood sugar can occur in people with diabetes who take certain medications to keep their blood glucose levels in control. It can be treated by eating or drinking something with carbohydrate. But left untreated, very low blood sugar can lead to loss of consciousness, seizure, or coma. It may even be fatal.

Although low blood sugar can happen suddenly, it can usually be treated quickly, bringing your blood glucose level back to normal. If your goal is tight control, talk to your health care team about ways to prevent low blood sugar and how best to treat it if it does occur. Ask if having a glucagon kit at home and at work is appropriate for you. This is particularly important if you have type 1 diabetes. Your family, friends, and co-workers will need to be taught how to give you a glucagon injection in an emergency.

A: The honeymoon period usually refers to a period when insulin needs are reduced. It often occurs shortly after starting insulin therapy in most cases of type 1 diabetes. Insulin production and the blood sugar levels temporarily improve. Its duration vary greatly. It may not appear at all for some people. Or, it may lasts for weeks, months, or even longer.

Low doses of insulin, if any, are usually required during this period. It only appears that the diabetes is reversed….at least temporarily. The honeymoon period is often confusing for everyone. - Liz Quintana, MS, RD, LD, CDE

Although you have not eaten during a fast, the cells in your body continue to need glucose. During the night the hormone glucagon is released stimulating the liver to produce glucose. If you body is producing insulin it will balance the rise in blood glucose levels and maintain the level between 70-100 mg/dl. A result above 126 mg/dl is considered to be diabetes; however a repeat test is frequently done if the level is only slightly elevated.

Random Plasma Glucose although the fasting plasma glucose test is the preferred test for diagnosing diabetes the random plasma glucose may also be used. A random plasma glucose test may be drawn any time of the day. A random plasma glucose of 200 or above and the presence of any of the symptoms of diabetes – extreme thirst, blurred vision, frequent urination, fatigue, slow healing wounds, extreme hunger, unexplained weight loss, numbness or tingling of the hands and feet, mood swings, irritability, or frequent recurring infections is a considered to be diabetes.

Although you have not eaten during a fast, the cells in your body continue to need glucose. During the period of fast, the hormone glucagon is released stimulating the liver to produce glucose. If you body is producing insulin it will balance the rise in blood glucose levels and maintain the level between 70-100 mg/dl. In individuals with type 2 diabetes, enough insulin may not be produced to keep your blood glucose levels within the normal range. An elevated fasting blood sugar is frequently the first indication an individual may have type 2 diabetes. A result above 126 mg/dl is considered to be diabetes; however a repeat test is frequently done if the level is only slightly elevated.

Random Plasma Glucose: although the fasting plasma glucose test is the preferred test for diagnosing diabetes the random plasma glucose may also be used. A random plasma glucose test may be drawn any time of the day. A random plasma glucose of 200 or above and the presence of any of the symptoms of diabetes – extreme thirst, blurred vision, frequent urination, fatigue, slow healing wounds, extreme hunger, unexplained weight loss, numbness or tingling of the hands and feet, mood swings, irritability, or frequent recurring infections is a considered to be diabetes.

Another test that may be done to diagnosis diabetes is an oral glucose tolerance test (OGTT) is usually done in the morning because a fasting blood glucose level is required. You must fast 8-12 hours before having the test done. You will have a fasting blood glucose done and then you will be given a 75 gram glucose solution to drink. Blood is then drawn at intervals to determine your blood glucose levels. The results are as follows:

Fasting: 70 to 100 mg/dL 1 hour: less than 200 mg/dL 2 hours: less than 140 mg/dL. A result between 140-200 mg/dL is considered impaired glucose tolerance or pre-diabetes. Individuals with impaired glucose intolerance or pre-diabetes are at increased risk for developing diabetes. A result greater than 200 mg/dL is diagnostic of diabetes mellitus

Although you have not eaten during a fast, the cells in your body continue to need glucose. During the period of fast, the hormone glucagon is released stimulating the liver to produce glucose. If you body is producing insulin it will balance the rise in blood glucose levels and maintain the level between 70-100 mg/dl.

In individuals with prediabetes, enough insulin may not be produced to keep your blood glucose levels within the normal range. An elevated fasting blood sugar is frequently the first indication an individual may have prediabetes diabetes. A result between 100 -125 mg/dl is considered to be prediabetes.

Fifty-eight percent of individuals with prediabetes, in a large research study, the Diabetes Prevention Program made lifestyle changes – decreasing their weight by 5-7% and walking for 30 minutes 5 days a week did not develop type 2 diabetes. Diabetes is preventable if lifestyle changes are made.

Random Plasma Glucose: although the fasting plasma glucose test is the preferred test for diagnosing diabetes the random plasma glucose may also be used. A random plasma glucose test may be drawn any time of the day. A random plasma glucose result of 140-199 mg/dl is considered prediabetes.

Another test that may be done to diagnosis pre-diabetes is an oral glucose tolerance test (OGTT) is usually done in the morning because a fasting blood glucose level is required. You must fast 8-12 hours before having the test done. You will have a fasting blood glucose done and then you will be given a 75 gram glucose solution to drink. Blood is then drawn at intervals to determine your blood glucose levels. The results are as follows:

Fasting: 70 to 100 mg/dL 1 hour: less than 200 mg/dL 2 hours: less than 140 mg/dL. A result between 140-200 mg/dL is considered impaired glucose tolerance or pre-diabetes. Individuals with impaired glucose intolerance or pre-diabetes are at increased risk for developing diabetes. A result greater than 200 mg/dL is diagnostic of diabetes mellitus

A: When you test your blood glucose the reading only represents the result at one point in time. While the A1C measures your overall control for the past 2-3 months. Frequently individuals only test their fasting blood glucose and never realize that their blood glucose is very elevated after eating a meal. It is important to test your blood glucose levels at varying times of the day in order to evaluate your levels before a meal and after a meal. It is also important to test your blood glucose when you medication is at the highest level and lowest level. You may not need to do this every day. But in order to gain an understanding of your overall control it is important to test at varying times. Also frequent low blood glucose levels may result in large excursions in blood glucose if you eat a large amount of carbohydrate to compensate for the low blood glucose your blood glucose may rise excessively. If you test your blood glucose and it still does not match you may want to speak with your physician in order to gain a better understanding of the results. You can also get more information here at dLife.com:

A: If your blood sugar is too low, you should eat 15 grams of a fast acting sugar such as glucose tablets, orange juice, or hard candy. Test your blood sugar again in 10 minutes if it is still dropping you may need an additional 15 grams of carbohydrate. If you are due to eat a meal, it is best to not delay. It is important for you to determine why your blood sugar dropped – did you skip a meal, take too much medication or insulin, exercise more intensely? If you have frequent low blood sugar reactions it is important to talk to you health care professional to determine if your medication regimen needs to be adjusted. - Kathleen Gold, RN, MSN, CDE

A: You don't say what medications you are taking and what time you are taking them. If you are taking insulin or a medication that increases your insulin production such as Amaryl, Glyburide, or Glipizide, you should be taking those medications before dinner. If you are taking insulin such as 70/30 Novolog, 70/30, these insulins are generally taken before dinner, taking them later may result in your insulin peaking at a time when you do not have an elevated blood sugar resulting in a low blood sugar reaction. If you are taking Lantus at night some patients find taking it the morning may reduce their risk of a low blood sugar.

To prevent a low blood sugar you could eat an evening snack but it may be better to discuss with your health care provider if you need to reduce the medication you are taking. Testing your blood sugar before bedtime also may provide information to determine if you need a snack. If you blood sugar is lower than 160 you should eat a snack. Some individuals benefit from some extra protein at night to prevent the low blood sugar in the middle of the night. However in most cases it is best to reduce your medication or insulin dose.

Are you engaging in vigorous physical activity on the days before your low reaction? If so you may need to decrease your dose of medication on days of heavy exercise, exercise may lower blood sugars for a number of hours after being completed. Discuss with your health care professional what adjustments you may need to make to prevent low blood glucose reactions. - Kathleen Gold, RN, MSN, CDE

A: A1C stands for "hemoglobin A1c. Hemoglobin is part of red blood cells that spend life traveling around the body through the blood stream. Also dissolved in your blood stream is "sugar" or glucose. Red blood cells only live for 3 months before the body replaces them with new ones. Think of your blood as a sugar solution. Red cells spend their life floating in this solution. Because of this, they eventually get coated with sugar. After a blood sample is taken, a lab can analyze the red blood cells and see how much sugar they are coated with. Non-diabetic red cells are coated with about 4-6% of sugar so they have an A1C of 4-6%. For every one percent an A1C goes up or down, it means that your 3-month blood sugar average has gone up or down by 35 points. An A1C of 7 % means that your blood sugar has been averaging 170 (mg/dL) for the life of the red cells or for the last 3 months. An A1C of 8% would mean that it has been averaging about 205. An A1C of 9% would mean that it has been averaging about 240, and so on.

Currently most diabetes doctors recommend that you try and keep your A1C levels under 7% and as close to 6% as possible. An A1C of 6% means that your blood sugar is averaging in the non-diabetic range. It's almost as if your blood does not have diabetes anymore and this is great!

Studies have indicated that if you have an A1C of 6% you are much less likely to develop long-term diabetes complications like heart, kidney, or eye disease. A higher A1C result rises puts you more at risk for complications. This is the main reason why knowing your A1C % is so important.

If you use a blood glucose meter to check your blood sugar throughout the day, you can take the blood sugar average from your meter for the last 3 months and compare it to your A1C. The blood sugar average reflected in your A1C should "jive" with what your meter average is. Let's say that you check your blood sugar twice a day before meals and the level is usually around 100 (mg/dL). But your last A1C was 8%, which is telling you that your 3-month average has been 205 (mg/dL). This does not mean that your meter is wrong (even though you should check to see if it is working correctly). It means that your blood sugar must be rising pretty high after meals or in the evening. You should start checking your blood sugar at these times to confirm what is happening. You may need changes in your current medication, food choices or portion sizes.

Your best bet to keep your A1C close to normal is to work with a team including your doctor, a dietitian, a nurse-certified diabetes educator and anyone else who can help you. Blood sugar averages come down with healthy eating, activity, and weight loss, decreasing stress, adequate medication and preventing/ managing infections. But you can't control what you don't know so if you don't have a glucose meter get one and learn how to test your sugar levels. Then you will be able to see how these everyday things can be used to control your blood sugar. Once you get the everyday things under control, your A1C will be under control. It is recommended that people with diabetes have an A1C check done every 3-6 months. Good Luck! - Donna Yuscavage, RN, BSN, CDE

A: I am sorry you are scared to go too far from home because of your diabetes. This is not an uncommon fear. But, with a little support and education, you can learn that living with diabetes means you can do 99.9% of anything you did before you were diagnosed.

Low blood sugar reactions (hypoglycemia) are a fact of life for many people with diabetes but they can be controlled. The main way to prevent them is to learn how to balance your medicine, food and activity. And of course, you need to use a glucose meter to check your sugar levels because you can't balance or control what you don't know. Here are several things you can to decrease your risk of low blood sugar:

1. Know your meds. Insulin and pills that stimulate the body to make insulin may cause low blood sugar reactions. Know the medicine you are taking, how it works, your dose, if can cause low blood sugar (not all do), and if your medicine has a "peak" time where it is working strongest. Too much medicine is one cause of low blood sugar (hypoglycemia).

2. Count carbs. Not enough carbohydrate (carb) in your meals, missed meals, and delayed meals may result in a low blood sugar reaction. To decrease your risk, learn how to count the carb content of food and how to "balance" the amount of carb with the amount and timing of your medicine. People on certain types on insulin and some short acting diabetes pills can prevent lows by decreasing their medicine if they don't plan to eat much or if they skip a meal. People on other medicines don't have this option and need to eat consistent amounts of carb throughout the day. Carb counting sounds like a complicated process but it really it's just a big word. If you can use a cell phone or a TV clicker, then learning how to count carbs should be a piece of cake! Find a Registered Dietitian (RD) who is experienced in diabetes and he or she will be able to teach you how to count and balance your carbs, and give you other tips as well.

3. Exercise safely. Exercise is one of the best things you can do for your health. But if you are on insulin or a medicine that stimulates your body to make insulin, exercise may cause a low blood sugar reaction either during the activity and/or later on in the day. Learn how to balance your medicine with activity. In general, before each hour of planned physical activity eating/drinking one extra carb serving or decreasing diabetes medicine should prevent low blood sugar. People taking rapid acting insulin and diabetes pills can may either decrease the amount of medicine or add a carb before exercise. Others who take longer acting medicine only have the option of eating more.

There are several more ways to prevent low blood sugar if you are on insulin. • Insulin pump users can adjust their insulin rates to decrease risk. • Avoid injecting insulin into parts of the body that will be used during the exercise. • Insulin users should avoid exercise during their insulin's "peak."

Work with your doctor or a Certified Diabetes Educator to learn how to balance medication and exercise. Don't try to do it on your own.

4. Watch alcohol. Alcohol lowers blood sugar so people with diabetes who drink alcohol need to know how to do it safely. Moderate alcohol use (one drink a day for a woman, two drinks a day for men) can usually be worked into a diabetic mean plan if balanced with food, medicine and activity. A Registered Dietitian would be the best person to advise on this issue.

5. Know your numbers. Get a glucose meter; learn how to use it, how often to test, and what to do with the results. Check before, during and after exercise and travel. Check before leaving home and always check before driving a car. Work with your doctor, dietitian or nurse educator to identify where your numbers should be and how to keep them from dropping. Know the early warning signs of low blood sugar and how to treat it. We now have glucose meters that plug into your stomach and send your blood sugar readings almost continuously to a device that you wear like a beeper. These meters sound an alarm if your sugar is too low or starts to fall rapidly. Many people with type 1 diabetes can get insurance coverage for these meters, but they are not covered for people with type 2 diabetes and are expensive.

6. Plan ahead. Make plans before traveling with diabetes. It is best to work with a diabetes educator on this one. In general you need to learn how to carry your medicine, food, glucose tablets, and your testing supplies and what to do to adjust for time zones. Carry diabetes identification, extra prescriptions and your physician and pharmacy name and number. Before flying, contact the airlines to find out if you need to do anything special in order to carry food, your medicine or your testing supplies. Keep your medicine and testing supplies on your person and do not put them into bags that are going to be checked. Carry a cell phone.

Finally, spend time with a dietitian and diabetes educator to get tips on dining out and eating at special events like parties. For example, medicine times can be adjusted if you plan to eat a lot later than usual. A dietitian can help you learn to make healthy restaurant choices, what to do if your meal is served late and even how to safely finish off your dinner with a glass of wine.

I suspect that all this information seems like a lot. Don't be overwhelmed. It is a lot because we KNOW a lot about what causes low blood sugar and how to decrease risk for having a reaction. Isn't that great? Learning how to manage diabetes well is like learning to ride a bike. It takes help and effort and coordination and practice. But one day, suddenly you're just riding along all by yourself and having fun to boot! I'm wishing you many wonderful adventures and experiences in faraway places! - Donna Yuscavage, RN, BSN, CDE

A: Ketones are dangerous acidy chemicals that appear in the blood and spill over into the urine when not enough insulin is present in your body. Without insulin your body cannot use sugar (glucose) for fuel. It turns to an alternate source of energy and burns body fat instead. Unfortunately, using fat for fuel poisons the blood. Think of ketones as pollution, which poisons and dehydrates the body. Ketones are also produced when not enough food is eaten to provide you with glucose. Ketones in the morning can be a sign that your body did not get enough fuel from glucose during the night resulting in a low blood sugar reaction while you were sleeping.

Most people with type 2 diabetes have enough insulin and so they do not usually have a problem with ketones. People with type 1 diabetes make very little or no insulin at all and are more at risk for ketones. The four main causes of ketones are illness/infection, forgetting to take insulin, not having enough insulin, and traumatic stress such as an accident. For those with type 1, testing for ketones is very important. These are reasons to test:

• A blood sugar over 240 (mg/dl) fasting or over 300 (mg/dl) during the day often happens when you do not have enough insulin. These numbers are usually a warning that your body is getting ready to switch its fuel source to fat and your blood may become polluted from ketones. • When you are sick or nauseated ketones can start forming, even if your sugar is not high. When ketones are present, it is a good idea to recheck every 4 hours. • Newly diagnosed type 1 people should check twice a day or more often if the check is positive for ketones. After a few days, if all checks have been negative, daily testing of ketones is no longer necessary.

Small to moderate ketones may be treated by some doctors at home. This is done by: 1. Prescribing extra insulin (usually regular or Novolog or Humalog or Apridra) 2. Drinking plenty of water to prevent dehydration. 3. Avoid exercising because it may cause fatter burning and more ketone production.

If you develop moderate or large amounts of ketones, call your doctor immediately. High blood sugars combined with moderate high ketones could be a sign of diabetic ketoacidosis (DKA). This condition is very serious and must be treated with extra insulin and intravenous fluids and medicines. Besides high blood sugar and ketones, other signs of DKA include:

Ketones can be checked by dipping a test strip into a urine sample or by using certain blood glucose meters. Urine test strips come in vials or can be individually packed in foil. Different brands have different directions and must be timed before reading. Ketones in the urine cause the strip to change different shades of color, which correlate with readings such as normal, small, moderate or large. Several brands of glucose meters will signal you to check for ketones if they detect a blood sugar reading of over 240 mg/dl. A couple meters have special ketone testing strips that can be used for testing the amount of ketones in the blood. Apply blood to and insert the ketone testing strip into the meter instead of inserting the blood glucose strip. Follow the meter instructions for how to interpret meter results. In general, a reading under 0.6 (mmol/l) is considered normal. 0.6 – 1.5 is considered small. Over 1.5 is considered moderate and 3.0 or more is considered large. Trace, small and moderate blood or urine readings should be reported to your physician. Moderate results should be reported immediately. If you have a blood sugar over 240 and large ketones, you should go directly to an emergency room.

If you have type 1 diabetes, always keep a supply of ketone test strips on hand. Individually foil-wrapped ketone test strips generally do not expire for 2 or 3 years. Ketone test strips that come in a vial must be discarded within 6 months of opening. Blood testing gives more current results but is more expensive. Always check with your physician about when and how often to check for ketones and what action to take for the results. – Donna Yuscavage, RN, BSN, CDE

A: Most blood glucose monitors are very reliable and all meters will vary in their results from time to time. There are different possibilities as to why you get different results:

1. Extra squeezing from the same finger poke to get a second drop of blood can result in more interstitial fluid than blood, and these different body fluids may result in varying results.

2. Different fingers can produce different results.

3. A few minutes time between tests can also result in variance, as blood sugar levels can change very quickly.

4. Elevation and anemia can both make results vary.

5. Meter not coded correctly.

6. Site of blood sample not cleaned before pricking.

7. Wet alcohol present at time of pricking. (can cause a false high reading)

What is important to remember (though frustrating), is that a 20% variability between meters, or even with the same meter, is considered, by FDA standards, adequate to pass the "meter test". The best way to know if your meter is correct is to use the control solution regularly (recommended use with every new vial of strips). If the result falls within the range listed on the back of the vial, it is considered good to go. I feel it is best to remember that no meter will necessarily match lab value, point for point. What is important is to know what area your BG is in so you can make the best judgment call for our own self care. For additional information, check out dLife's information on testing. - Anne Carroll, RN, CDE

A: Much like an insulin pump insertion set, a continuous glucose monitor (CGM) uses a sensor placed under the skin in the subcutaneous tissue (fat). The difference between the two is that the pump delivers insulin, while the sensor collects interstitial fluid. A pump site needs to be changed at least every 3 days, while a CGM sensor can be worn for up to 6 days.

The CGM is a remarkable tool that can help a person dependent on insulin recognize which direction his blood glucose level is going, be it up or down. These "trends" can be a great help, particularly for those who suffer from hypoglycemia unawareness or who often find themselves with extremely high blood sugar levels but no sign or symptoms to speak of. High and low targets are determined by the user. Alarms sound when these targets are reached, or when the blood sugar is rising or dropping at a rapid rate. It is of utmost importance that the wearer recognize that any changes in care, be it insulin for a high or treatment for a low, MUST be verified by self-monitoring of blood glucose (SMBG). My personal experience wearing a CGMS unit was quite positive. I was alerted to rises and drops in BG in their early stages and, after SMBG, was able to take effective action in a timely manner. There were times, however, where I had to test with my meter because I "didn't believe" the CGMS unit. At those times, I was nearly always correct. In my personal opinion, CGMS is a great tool with a lot of promise, which is sure to be ever improving in the near future. dLife has information on continuous glucose monitoring if you want to know more. - Anne Carroll, RN, CDE

If you use insulin before every meal, then your minimum testing will be 3 times daily (before each meal), and preferably before bedtime as well. Optimum testing for the tightest control also includes tests 1 to 2 hours after the start of each meal. This will ensure that your mealtime insulin is meeting your metabolic needs for the carbohydrates you have eaten. It's a complicated process and the more data you can obtain from frequent self-monitoring of blood glucose (SMBG) the better.

If you use a pre-mixed insulin which is taken twice daily, SMBG 2-4 times each day will generally suffice.

If you use oral agents or diet and exercise alone, it is a good idea, initially, to test first thing every morning (fasting blood glucose-FBG), and 2 hours after the start of each meal. Generally, SMBG this frequently only needs to be done until patterns of good glucose management have been established. In other words, once your BG is staying in a fairly consistent range, most people will decrease SMBG to 1-2 times daily. I most often recommend FBG each morning, plus one other post-meal test, varying the time of this test from day to day so that BG levels following each meal can be established after a week or two of testing.

How do you know if you're testing enough? If the 30 day average on your BG meter matches closely to the corresponding average of your A1c result, (which should be done every three months), then you are probably testing plenty. If, however, your A1c result is higher than your BG average, you should probably ramp up the SMBG to discover just when your BG is climbing and therefore enable yourself to make necessary changes. For additional information, you may want to click here. - Anne Carroll, RN, CDE

by
Lindsey Guerin
Today marks 22 years with type 1 diabetes for me. It doesn’t seem real. When I see other diabetics who have had it for 40, 50, 60 years, it just makes it feel like there is so much further to go. An endless amount of this life. 22 years is a lifetime for me. It is 85% of my life…22 years out of just 26. And I don’t even remember the first four diabetes-free years. Do not get me wrong. I am grateful for a fairly healthy 22 years. I do not have complications. I have been blessed to...